AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (Electronic Funds Transfer)

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Please note if you already have an account on file you do not need to fill out another form.

Email *

Dancer's Last Name *

Dancer's First Name(s) *

I understand and accept the following: *

Allegro Dance Studio has permission to deduct my Summer Tuition from my specified account. Deduction will begin on June 28, 2024.

I understand and accept the following: *

I understand that a $20.00 NSF will be charged if adequate funds are not available. If this happens, you will be contacted by email. Allegro Dance Studio will not make a second attempt via EFT to collect funds. Account must be made current by paying with check or cash and will include the $20.00 Fee.

I hereby authorize Chase Bank to initiate entries to my Financial Institution:

Debiting Account - Your Financial Institution *

Name on Account *

Routing Number (from check not deposit slip) *

Account Number *

Amount to be debited: *

Signature of Debiting Customer (Please type your Name as Signature) *

Date of Signature *

YYYY

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